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Outpatient-Based Bone Marrow Transplantation for Hematologic Malignancies: Cost Saving or Cost Shifting?

From the School of Medicine, School of Nursing, Oncology Center, and Program for Medical Technology and Practice Assessment, Johns Hopkins University, Baltimore, MD.

Address reprint requests to J. Douglas Rizzo, MD, International Bone Marrow Transplant Registry/Autologous Blood and Marrow Transplant Registry Statistical Center, 8701 Watertown Plank Rd, Milwaukee, WI 53226; email rizzo{at}mcw.edu

PURPOSE: To determine whether a shift in care from an inpatient-based to an outpatient-based bone marrow transplantation (BMT) program decreased charges to payers without increasing clinical complications or out-of-pocket costs to patients.

PATIENTS AND METHODS: This nonrandomized prospective cohort study compared clinical and economic outcomes for 132 consecutive BMT patients with hematologic malignancies who received either inpatient- or outpatient-based BMT care.

RESULTS: Seventeen of 132 BMT patients underwent outpatient-based BMT. Compared with the inpatient-based group, the outpatient-based group had a markedly lower mean number of inpatient hospital days (22 v 47; P < .001) and decreased mean inpatient facility charges ($61,059 less per patient; P < .0001) but had higher mean outpatient facility charges ($49,732 higher; P < .0001). Total professional fees were similar for the groups. The mean total charge to payers was only 7% less ($12,652; P = .21) for outpatient-based BMT than for inpatient-based BMT, but total charge was 34% less for outpatient compared with inpatient BMT ($54,240; P = 0.056) in a subset of patients who had a standard rather than high risk of treatment failure. There was no significant difference between groups in out-of-pocket costs for transportation, lodging, meals, home nursing, household assistance, child care, medication expenses, or unreimbursed medical bills. There also was no significant difference between groups in reported income lost, involuntary unemployment, or months of disability. The two groups had similar rates of major complications, including death, significant acute graft-versus-host disease, and veno-occlusive disease of the liver.

CONCLUSION: Increased use of outpatient-based BMT should produce substantial cost savings for payers without adverse effects on patients for those patients who do not have a high risk of treatment failure.

This work was supported by National Cancer Institute grant no. P01CA15396 and by the Johns Hopkins Hospital, Baltimore, MD.

J.D.R. was supported by a research fellowship from the Robert Wood Johnson Clinical Scholars Program during the conduct of this project.

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